Metabolic Disturbances

Metabolic Acidosis
Description
- ↑ Gap: ↑ Production; ↓ Excretion of H+
- ↔ Gap: Loss of HCO3- or ingestion of H+ / Cl- ions
Presentation
- Features: Lethargy; Headache
- Severe: Neurological / Cardiac sx if extreme
- Compensatory: Hyperpnoea; Hypoxia
Causes
- Metabolic Acidosis with ↑ Anion gap
o Lactic acidosis: Shock; Infx; Ischaemia
o Urate: Renal failure
o Ketones; DM; Alcohol
o Drugs: Salicylates; Biguanides; Methanol
- Metabolic Acidosis with ↔ Anion gap
o Renal: Renal tubular acidosis
o GI: Diarrhoea; Pancreatic fistula
o Endocrine: Addison’s disease
o Drugs: Acetazolamide; Spironolactone
o Miscellaneous: NH4CL ingestion
Causes
- ABG: ↓ pH; ↓/↔ PaCO2; ↓ HCO3

Metabolic Alkalosis
Presentation Causes
- Features: Arrythmia; Myalgia; Tetany; Seizures - H+: Vomiting (HCl loss); HCO3- gain (Seltzer/infusion)
Investigations - ↓ K+: Conn’s; Diuretics; Cushing’s; Bartter’s
- ABG: ↑ pH; ↑/↔ PaCO2; ↑ HCO3 - Other: Burns; Liquorice; Ingestion of base

Respiratory Acidosis
Presentation Causes
- Features: Confusion; Anxiety; Asterixis; Hypopnoea - Neurological: Leads to respiratory depression
Investigations - Lung: COPD (10 % CO2 retainers); Pneumonia
- ABG: ↓ pH; ↑ PaCO2; ↑/↔ HCO3 - Other: Benzodiazepines; Opiates; Pickwickian
Syn.
Respiratory Alkalosis
Presentation Causes
- Features: Arrythmia; Hyperpnoea; Tetany; Seizures - CNS: Stroke; SAH; Meningitis; Encephalitis
Investigations - Pulmonary: Mild Asthma; PE (reflex ↑RR)
- ABG: ↑ pH; ↓ PaCO2; ↓/↔ HCO3 - Other: Salicylates; Altitude; Pregnancy; Anxiety

ABG Interpretation
Terminology pH PaCO2 HCO3
Respiratory Acidosis ↓ ↑ ↔
Respiratory Alkalosis ↑ ↓ ↔
Metabolic Acidosis ↓ ↔ ↓
Metabolic Alkalosis ↑ ↔ ↑
Hypernatremia
Presentation Management
- Early: Headache; Lethargy; N&V; Confusion; Myalgia; - Initial: Oral water intake (best option)
Jittery movements; Hypertonia - Normo/Hypervolaemia: 5 % Glucose IV slowly (6
- Late: Seizures; Coma; Resp. arrest; Hyperreflexia hr)
Causes - NB: Glucose is metabolised quickly  Hypotonic
- Common : Iatrogenic; Diarrhoea; Vomiting; Burns - Hypovolaemia: 0.9 % Saline IV if hypovolaemic
- Uncommon: Diabetes insipidus; 1o Aldosteronism - NB: Fluid is still hypotonic to patient
Investigations
- Bloods: ↑ Na+; ↑ PCV; ↑ Albumin; ↑ Urea
- Mild: 146-149 mmol/L
- Moderate: 150-159 mmol/L
- Severe: ≥160 mmol/L

Hyponatremia
Presentation Management
- Early: Headache; Malaise; N&V; Confusion; Oedema - Chronic Hyponatraemia
- Late: Seizures; Coma; Respiratory depression o Hypovolaemic: Isotonic Saline (0.9 % NaCl)
Causes o Euvolaemic: Restrict to 500-1000 mL/d
- Urinary Sodium >20 mmol/L o NB: Consider Demeclocycline or Vaptans
o Na+ Loss: Thiazides; Furosemide; Addison’s; RF o Hypervolaemic: Restrict to 500-1000 mL/d
o Euvolemic: SIADH; Hypothyroidism o NB: Consider Furosemide or Vaptans
- Urinary Sodium <20 mmol/L - Acute Hyponatraemia
o Na+ Loss: D&V; Sweating; Burns; Rectal adenoma o Severe: HDU or ICU admission
o ↓ Excretion: 2o Hyperaldosteronism; Nephrotic o Seizures: 100 mL Hypertonic saline (3 %) 15
o ↑ Intake: IV Dextrose; Psychogenic polydipsia min
Investigations o Key: Max increase 10-12 mmol/L in 24 hr
- Type of Hyponatremia period
o Acute: Develops <48 hrs Complications
o Chronic: Develops >48 hrs - Rapid Correction: Central Pontine Myelinolysis
- Severity of Hyponatremia (Osmotic demyelination Syn.); Cerebral Oedema
o Mild: 130-134 mmol/L
o Moderate: 120-129 mmol/L
o Severe: <120 mmol/L

Hyperkalaemia
Presentation Management
- Chest pain: Fast irregular pulse; Palpitations; SOB - Emergency: Severe or ECG changes seen
- Malaise: Light headedness; Weakness; Vomiting - Non-urgent: Polystyrene sulfonate resin
Causes - Stabilise Membrane: IV Calcium Gluconate
- Renal: AKI; Rhabdomyolysis - ECF  ICF Shift: Insulin + Dextrose; Salbutamol
- Endocrine: Metabolic acidosis; Addison’s disease - Remove K+: Ca2+ resonium; Furosemide; Dialysis
- Drugs: ACEi; ARBs; Spironolactone; Heparin
- Other: Massive blood transfusion
- Artefactual: Haemolysis; Thrombocytopenia
Investigations
- ECG Findings
o P-Waves: Small or absent P-waves
o QRS: Wide QRS complex
o T-Waves: Tall-tented T-waves
o Severe: Sinusoidal; Ventricular fibrillation
- Severity of Hyperkalaemia
o Mild: 5.5-5.9 mmol/L
o Moderate: 6.0-6.4 mmol/L
o Severe: ≥6.5 mmol/L
Hypokalaemia
Presentation Management
- Muscle: Weakness; Hypotonia; Spasms; Tetany - Mild: PO K+; 3 d Review; Switch to Spironolactone
- Cardiac: Palpitations; TdP - Severe: IV K+; Max 10 mmol/hr and 40 mmol/L
- Malaise: Light headedness; Constipation - NB: Max 20 mmol/hr if CVC and ECG monitoring
Causes Complications
- ↓ H+: Vomiting; Diuretics; Cushing’s; Conn’s - Cardiac: Arrythmia (Bradycardia; TdP)
- ↑ H+: Diarrhoea; RTA; Acetazolamide; DKA mx (Insulin) - MSK: Muscle paralysis  Resp. Failure
- Nutritional: ↓ Mg2+; Purgatives; Liquorice
- ↑ BP: Endo; Liddle’s; 11-β Hydroxylase deficiency
Investigations
- ECG
o P-Waves: Small or absent P-waves
o QT: QT prolongation
o ST: Mild ST depression
o T-Waves: Visible U-wave
o Severe: Sinusoidal; Ventricular fibrillation
- Severity of Hypokalaemia
o Mild: 3.6 mmol/L <K+ >2.5 mmol/L
o Severe: <2.5 mmol/L

Hypercalcaemia
Presentation Investigations
- Stones: Kidney / Biliary stones - Other tests include
- Bones: Bone pain o Bloods: FBC; HIV test
- Groans: Abdominal discomfort o Imaging: CXR; Isotope bone scan
- Moans: Malaise o ECG: ↓ QT interval
- Thrones: Constipation + Polyuria; Renal Failure o Misc: 24 hr urinary Ca2+ excretion (FHH)
- Muscle tone: Myalgia + Hyporeflexia; Cardiac failure Management
- Psychiatric overtones: Depression; Memory loss - Fluids: Correct dehydration; 0.9 % NaCl
Causes - Bisphosphonates: Prevents bone reabsorption
- Common causes - NB: Take 2-3 d to work; Max effect at 7 d
o PTH: 1o Hyperparathyroidism - Calcitonin: Quicker than bisphosphates
o NB: Commonest cause in non-hospitalised Pt - Sarcoidosis: Steroids
o Malignancy: Myeloma; Bone Mets; PTH SCLC - Avoid: Thiazides
o NB: Commonest cause in hospitalised Pt
- Other causes
o Key: Sarcoidosis
o Endo: Thyrotoxicosis; Addison’s; Acromegaly
o Metabolic: Milk-alkali syndrome; Paget’s
o Drugs: VitD intoxication; Lithium; Levothyroxine
o Misc: Familial hypocalciuric hypercalcaemia (FHH)

Hypocalcaemia
Presentation
- Mild: Cramps; Perioral numbness; Paraesthesia
- Severe: Trousseau’s sign; Chvostek’s sign; Seizures
Causes
- ↑ PO43-: CKD: Hyperparathyroidism; Thyroid op; ↓Mg2+
- ↓ PO43-: ↓ VitD; Osteomalacia; Pancreatitis; Resp. Alk.
Management
- Mild: PO Calcium 5 mmol/6 hr
- CKD: PO Alfacalcidol
- Severe: 10 mL 10 % Ca2+ gluconate IV over 30
mins
- Respiratory alkalosis: Correct alkalosis
- NB: Total Calcium ↔ but ↓ Ionised Calcium
 Features of Hypercalcaemia
Sign Description
S Spasma (Trosseau's sign) ↑ Pressure over Brachial a.
P Perioral paraesthesiae Numbness around mouth
A Anxious/Irritable/Irrational -
S Seizures -
M Muscle tone ↑ Wheeze + Dysphagia
O Orientation impairment Confusion + ↓ Cognition
D Dermatitis Atopic/exfoliative
I Impetigo herpetiformis Pustular psoriasis in pregnancy
C Chvostek's sign Facial sign by tapping parotid (CNVII)
C Cataracts Chronic
C Cardiomyopathy Chronic

Hypophosphataemia
Presentation
- MSK: Myalgia; Rhabdomyolysis
- Haem: Erythrocyte/Leukocyte/Platelet dysfunction
- Cardio: Cardiac arrest; Arrythmia
Management
- Key: Insignificant unless severe (<0.4 mmol/L)
- Supplements: Oral or parenteral PO43-
- NB: Avoid IV if patient is ↑Ca2+ or oliguric
Causes
- Alcohol: Excess; Withdrawal
- Hepatic: Acute Liver Failure
- Nutritional: Malnutrition; Refeeding syn; ↓ VitD
- Bone: Osteomalacia
- Endo: 1o Hyperparathyroidism; DKA

Hypermagnesaemia Hypomagnesaemia
Presentation Presentation
- Features: : ↓BP; ↓Pulse; Paralysis  Resp. Failure - Features: Tetany; Ataxia; Paraesthesia; Arrythmia
Causes Causes
- Cx: Diuretics; DKA; Alcohol abuse
Management
- Supplements: Magnesium salt supplements
- Cx: Renal failure; Iatrogenic (excessive antacids)
Management
- None: Unless severe (>7.5 mmol/L)